Project: Centre For Minimal Access Surgery

2005
Canada health infostructure partnerships program (CHIPP)

Synopsis

The Centre for Minimal Access Surgery (CMAS), located at St. Joseph's Hospital in Hamilton, was launched in collaboration with the Department of Surgery within the Faculty of Health Sciences at McMaster University in October 1999, and has since achieved national and international recognition for its educational and research accomplishments.

CMAS utilizes an integrated video-conferencing system that permits high quality, rapid transfer of multi-feed video data of surgical procedures from an operating room to the classroom setting. These video feeds are accompanied by a two-way audio connection for immediate interaction between the learners and surgeons. This set-up allows training surgeons to gain a realistic perspective of minimal access procedures and to identify some of the difficulties commonly associated with them.

The CHIPP award allowed CMAS to build on its successes, including the expansion of its educational and training opportunities in the area of undergraduate education, to implement telementoring, and to move into the next phases of surgical intervention using telerobotics. CMAS is now able to increase the accessibility of Canadians in geographically remote areas to minimal access surgical procedures and to support and train those surgeons practicing in these remote areas thus encouraging their recruitment and retention.

Main Impacts

Telementoring

In telementoring an experienced surgeon (typically in an advanced treatment facility in a major urban centre) uses a two-way telecommunications link to guide the remote surgeon during an operation. This allows the remote physician, who may only have had some preliminary training in laparoscopic techniques, to gain confidence and experience under the watchful eye of an expert. Telementoring is used to support the remote surgeon while eliminating the need for travel and increases the mentor's availability to work with several different learning surgeons.

In the provision of telementoring it was found that in both locations, North Bay and Chicoutimi found benefit in terms of surgical support during an advanced laparoscopic case. Overall, telementoring was proven a successful tool in the provision of surgical care and support in this program and therefore has the ability to:

• increase the retention of surgeons in rural areas by providing access to continuing education opportunities
• improve a surgeons' minimal access skills and teaching them the latest techniques
• expand the number of procedures surgeons are comfortable performing

Telerobotics

With the proven success of telerobotics over a commercially available telecommunications network access to this type of surgical support is readily available.

• Surgeons in small community hospitals can now treat their patients within the community without the need for travel to tertiary care centers
• Surgeons can provide quality care through the accessibility of an expert surgeon telerobotically
• the community surgeon can receive hands on support and training in advanced laparoscopic procedures and continue to provide these services to their patients in the future
• the access to continuing medical education and research that this type of program offers a community surgeon helps professional isolation that many community surgeons feel
• access to this type of support and training helps an institution to recruit and retain surgeons within their community
• this type of critical mission telehealth application offers OR nursing staff, IT professionals and other allied health professionals increased scope in their duties and over time create more jobs in a community
• in terms of issues the provinces face such as the most recent SARS epidemic, the implementation of telementoring and telerobotics would mean uninfected communities could still received quality health care without traveling to infected areas
• with the implementation of applications such as this other telehealth applications such as telepathology, e-endoscopy and e-colonoscopy can be implemented and with the addition of telediagnostics and the availability of the EHR a full complement of services can be offered to the rural and remote patients without the need for travel

Lessons Learned

Telerobotic surgery and this type of mission critical telehealth application represents a paradigm shift in the delivery of surgical care-it is a revolutionary, rather then an evolutionary transformation. As with other previous transformational changes in medical practice, such as laparoscopic surgery, it may not be readily accepted - yet.

Telerobotic surgery, and the use of robotics in education and surgical support represent a revolutionary shift for the future and will establish a significant position in the surgical world providing substantial benefits to the medical field and patients both nationally and internationally and world wide.

Telesurgery is a vehicle for expanding accessible, quality and responsible health care practice into areas where expertise does not currently exist. It may take some years for telerobotic surgery to gain full acceptance, however, the clinical practice and technology has been introduced, proven and met with complete success. Like any innovative and revolutionary clinical practice, once established and proven cost effective it has the potential to become mainstream.

Policy And Research Implications

Major Finding #1

Current telecommunication networks that are in place provincially should be audited in terms of their mandates. It is an economic hardship to ask institutions to develop their own networks to participate in telehealth applications such as ours. There is another group that supports diagnostic imaging, NORAD, that also had to develop their own network at a great cost.

If the bandwidth and info structure is currently in place then policies and procedures should be altered to include mission critical telehealth applications such as these. Our program could assist in the development of such mandates, the technological requirements and the adaptability of the network.

Major Finding #2

The implementation of such a mission-critical telehealth application that could potentially impact cross-jurisdictional health care provision, such as telementoring and telerobotics, could in parallel, assist in the development of a national licensing structure, fee structure and assist in the development of national standards for telehealth coordinators, program managers, nurses, IT analysts and allied health professionals. CMAS could assist in the development of a national licensing structure, fee structure, and national standards for telehealth coordinators, program managers, physicians, nurses, IT analysts and allied health professionals.

Major Finding #3

The ability of this program to bring together academic institutions, community institutions, surgeons and industry partners such as Bell Canada, in an innovative application gave the group experience in the development of standards to support telehealth applications that directly impact patient care and outcome such as telementoring and telerobotics. These standards include minimum bandwidth requirements, security and safety measures, minimum equipment standards, ethics support, consent and information sheets, training standards and partnership agreements. All of these tools could be developed to be applicable nationally and across provincial boundaries.

Development of these standards cannot be done in isolation but rather should be developed and adapted in parallel with the expansion of this type of mission critical telehealth application. By doing so the newest developments in technology can be addressed as they are developed and applied, and their implications on standards and policies addressed directly, new advances in the types of services that are developed in terms of other disciplines and other applications such as telepathology and telediagnostics can also be addressed directly.

Documents or Products Generated

Document/ Product Name	Available in Paper and/ or Electronic Form	Licence Fee Required for use (Yes/No)
Partnership Agreements	Paper/electronic form	No
Evaluation templates	Paper/Electronic form	No
Patient Information sheet	Paper/electronic form	No
Patient consent form	Paper/Electronic form	No

For additional information please contact:

Dr. M. Anvari at 905-522-1155, Ext. 5144 or via anvari@mcmaster.ca